A 12-month follow-up study of the course of body dysmorphic disorder

Predictors of pharmacotherapy outcomes for body dysmorphic disorder: a machine learning approach

BACKGROUND

Serotonin-reuptake inhibitors (SRIs) are first-line pharmacotherapy for the treatment of body dysmorphic disorder (BDD), a common and severe disorder. However, prior research has not focused on or identified definitive predictors of SRI treatment outcomes. Leveraging precision medicine techniques such as machine learning can facilitate the prediction of treatment outcomes.

METHODS

The study used 10-fold cross-validation support vector machine (SVM) learning models to predict three treatment outcomes (i.e. response, partial remission, and full remission) for 97 patients with BDD receiving up to 14-weeks of open-label treatment with the SRI escitalopram. SVM models used baseline clinical and demographic variables as predictors. Feature importance analyses complemented traditional SVM modeling to identify which variables most successfully predicted treatment response.

RESULTS

SVM models indicated acceptable classification performance for predicting treatment response with an area under the curve (AUC) of 0.77 (sensitivity = 0.77 and specificity = 0.63), partial remission with an AUC of 0.75 (sensitivity = 0.67 and specificity = 0.73), and full remission with an AUC of 0.79 (sensitivity = 0.70 and specificity = 0.79). Feature importance analyses supported constructs such as better quality of life and less severe depression, general psychopathology symptoms, and hopelessness as more predictive of better treatment outcome; demographic variables were least predictive.

CONCLUSIONS

The current study is the first to demonstrate that machine learning algorithms can successfully predict treatment outcomes for pharmacotherapy for BDD. Consistent with precision medicine initiatives in psychiatry, the current study provides a foundation for personalized pharmacotherapy strategies for patients with BDD.

A smartphone app for the prevention and early intervention of body dysmorphic disorder: Development and evaluation of the content, usability, and aesthetics

Body dysmorphic disorder (BDD) is an impairing condition characterized by excessive appearance concerns that frequently begin in adolescence, thus making this phase an eminent target for prevention and early intervention. We developed a cognitive-behavioral app-based program (AINA) intended for prevention and early intervention of BDD. As part of the iterative development process, perceptions of usability, aesthetics, and content were investigated. A sample of 38 adolescents and young adults aged between 14 and 21 years tested the app in a laboratory setting and completed a survey of diagnostic and user experience questionnaires. Overall, usability, aesthetics, and content of the app received positive evaluations. Regression analyses did not point to any large effects of age, gender, years of education, self-esteem, or BDD symptom severity on user evaluations. On average, participants had no concerns about privacy or data security of the app, indicating that these aspects will presumably not act as barriers to usage. Altogether, the present results are encouraging. Future research needs to examine whether AINA is an efficacious measure for prevention and early intervention of BDD.

Empirically Defining Treatment Response and Remission in Body Dysmorphic Disorder Using a Short Self-Report Instrument

Determining response or remission status in body dysmorphic disorder (BDD) usually requires a lengthy interview with a trained clinician. This study sought to establish empirically derived cutoffs to define treatment response and remission in BDD using a brief self-report instrument, the Appearance Anxiety Inventory (AAI). Results from three clinical trials of BDD were pooled to create a sample of 123 individuals who had received cognitive-behavioral therapy for BDD, delivered via the Internet. The AAI was compared to gold-standard criteria for response and remission in BDD, based on the clinician-administered Yale-Brown Obsessive Compulsive Scale, modified for BDD (BDD-YBOCS), and evaluated using signal detection analysis. The results showed that a ≥ 40% reduction on the AAI best corresponded to treatment response, with a sensitivity of 0.71 and a specificity of 0.84. A score ≤ 13 at posttreatment was the optimal cutoff in determining full or partial remission from BDD, with a sensitivity of 0.75 and a specificity of 0.88. These findings provide benchmarks for using the AAI in BDD treatment evaluation when resource-intensive measures administered by clinicians are not feasible.

Empirically defining treatment response and remission in body dysmorphic disorder

BACKGROUND

The number of clinical trials in body dysmorphic disorder (BDD) has steadily increased in recent years. As the number of studies grows, it is important to define the most empirically useful definitions for response and remission in order to enhance field-wide consistency and comparisons of treatment outcomes across studies. In this study, we aim to operationally define treatment response and remission in BDD.

METHOD

We pooled data from three randomized controlled trials of cognitive-behavior therapy (CBT) for BDD (combined n = 153) conducted at four academic sites in Sweden, the USA, and England. Using signal detection methods, we examined the Yale-Brown Obsessive Compulsive Scale modified for BDD (BDD-YBOCS) score that most reliably identified patients who responded to CBT and those who achieved remission from BDD symptoms at the end of treatment.

RESULTS

A BDD-YBOCS reduction ⩾30% was most predictive of treatment response as defined by the Clinical Global Impression (CGI) - Improvement scale (sensitivity 0.89, specificity 0.91, 91% correctly classified). At post-treatment, a BDD-YBOCS score ⩽16 was the best predictor of full or partial symptom remission (sensitivity 0.85, specificity 0.99, 97% correctly classified), defined by the CGI - Severity scale.

CONCLUSION

Based on these results, we propose conceptual and operational definitions of response and full or partial remission in BDD. A consensus regarding these constructs will improve the interpretation and comparison of future clinical trials, as well as improve communication among researchers, clinicians, and patients. Further research is needed, especially regarding definitions of full remission, recovery, and relapse.

Body dysmorphic disorder and cosmetic surgery: Evolution of 24 subjects with a minimal defect in appearance 5 years after their request for cosmetic surgery

Objectives

To evaluate the effect of cosmetic surgery and the stability of body dysmorphic disorder (BDD) diagnosis in patients with a minimal defect in appearance, with and without BDD, 5 years after their request for plastic surgery.

Subjects and methods

Thirty patients requesting cosmetic surgery with minimal defect in appearance, of whom 12 had BDD and 18 did not, were re-evaluated 5 years later by telephone interview regarding their cosmetic surgery interventions, satisfaction with the intervention, BDD diagnosis, handicap, and psychiatric comorbidity.

Results

Of the 30 patients, we were able to re-evaluate 24 subjects (80%), 10 with BDD and 14 non-BDD. Seven BDD subjects had undergone cosmetic surgery vs 8 non-BDD. Patient satisfaction with the intervention was high in both groups. Nevertheless at follow-up, 6 of the 7 operated BDD patients still had a BDD diagnosis and exhibited higher levels of handicap and psychiatric comorbidity compared to their non-BDD counterparts. Moreover, 3 non-BDD patients had developed a BDD at follow-up.

Conclusion

This prospective study confirms that cosmetic surgery is not efficient on BDD despite declared patient satisfaction. Cosmetic surgery had no significant effects on BDD diagnosis, handicap or psychiatric comorbidity in BDD patients at 5-year follow-up. Furthermore, BDD appeared at follow-up in some initially non-BDD diagnosed subjects. Patients' declared satisfaction with surgery may contribute to explain why some plastic surgeons may not fully adhere to the contraindication of cosmetic surgery in BDD.

Direct comparisons of anorexia nervosa and body dysmorphic disorder: A systematic review

Anorexia nervosa (AN) and body dysmorphic disorder (BDD) are serious psychiatric conditions, both of which are associated with a disturbance of body image. The aim of this paper was to review those studies that have directly compared groups of individuals with AN and BDD, to determine similarities and differences in presentation between the two conditions. The literature was searched to September 2018, and studies were included if they were English language, empirical research papers published in peer-reviewed journals, specifically comparing AN and BDD patients. Fifteen relevant studies were identified. The results suggested that individuals with AN and BDD share a number of similarities, including their degree of body dissatisfaction. Differences between the conditions included primary concerns with body shape and weight in AN, and much more diffuse concerns (but predominantly the face) in BDD. The small number of studies, along with the limited replication of results emphasises the need for greater research in this area. However, the studies undertaken to date highlight the high degree of overlap between AN and BDD and suggests that the conditions may represent similar body image disorders. This has implications for the nosological status of AN and BDD.

Long-term outcome of therapist-guided internet-based cognitive behavioural therapy for body dysmorphic disorder (BDD-NET): a naturalistic 2-year follow-up after a randomised controlled trial

OBJECTIVES

Most patients with body dysmorphic disorder (BDD) do not receive evidence-based treatment. A randomised controlled trial (RCT) has found that a therapist-guided internet-based cognitive-behavioural therapy (CBT) programme for BDD (BDD-NET) can be delivered safely via the internet with significant improvements in BDD symptom severity in the short term. The purpose of this study was to evaluate if the therapeutic gains of BDD-NET are maintained 2 years after treatment.

SETTING

Academic medical centre.

PARTICIPANTS

A naturalistic 2-year follow-up study of the 88 self-referred adult outpatients with a diagnosis of BDD that had received BDD-NET within the context of the RCT.

PRIMARY AND SECONDARY OUTCOMES

The primary outcome was the BDD-Yale-Brown Obsessive-Compulsive Scale (YBOCS). Responder status was defined as a ≥30% reduction in symptoms. Remission was defined as no longer meeting Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria for BDD. Secondary outcomes included measures of depression, global functioning and quality of life.

RESULTS

The efficacy of BDD-NET was sustained long- term, with further improvements observed on the BDD-YBOCS during the follow-up period. At follow-up, 69% (95% CI 57% to 80%) were classified as responders and 56% (95% CI 43% to 69%) were in remission. Gains on depressive symptoms and global functioning were also sustained but not quality of life. A majority of participants reported that the main reason for seeking help for their BDD was the possibility to access the treatment from home.

CONCLUSION

BDD-NET is an effective treatment for BDD, and the patients' gains are maintained in the long term. BDD-NET has the potential to increase access to CBT and may lower the threshold for BDD sufferers to seek help in the first place.

TRIAL REGISTRATION NUMBER

NCT02010619.

Pharmacotherapy Relapse Prevention in Body Dysmorphic Disorder: A Double-Blind, Placebo-Controlled Trial

OBJECTIVE

Body dysmorphic disorder is common, distressing, and often severely impairing. Serotonin reuptake inhibitors appear efficacious, but the few existing pharmacotherapy studies were short term (≤4 months), and no relapse prevention studies or continuation phase studies have been conducted to the authors' knowledge. The authors report results from the first relapse prevention study in body dysmorphic disorder.

METHOD

Adults (N=100) with DSM-IV body dysmorphic disorder received open-label escitalopram for 14 weeks (phase 1); 58 responders were then randomized to double-blind continuation treatment with escitalopram versus switch to placebo for 6 months (phase 2). Reliable and valid outcome measures were utilized.

RESULTS

In phase 1, 67.0% of treated subjects and 81.1% of subjects who completed phase 1 responded to escitalopram. Body dysmorphic disorder severity (in both the intent-to-treat and the completer groups) and insight, depressive symptoms, psychosocial functioning, and quality of life significantly improved from baseline to end of phase 1. In phase 2, time to relapse was significantly longer with escitalopram than with placebo treatment (hazard ratio=2.72, 95% CI=1.01-8.57). Phase 2 relapse proportions were 18% for escitalopram and 40% for placebo. Among escitalopram-treated subjects, body dysmorphic disorder severity significantly decreased over time during the continuation phase, with 35.7% of subjects showing further improvement. There were no significant group differences in body dysmorphic disorder severity or insight, depressive symptoms, psychosocial functioning, or quality of life.

CONCLUSIONS

Continuation-phase escitalopram delayed time to relapse, and fewer escitalopram-treated subjects relapsed than did placebo-treated subjects. Body dysmorphic disorder severity significantly improved during 6 additional months of escitalopram treatment following acute response; more than one-third of escitalopram-treated subjects experienced further improvement.

Cognitive-Behavioral Therapy for Adolescent Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is a relatively common and severe disorder that typically onsets in adolescence, but often goes unrecognized. Despite BDD's severity and early onset, treatment outcome research on adolescent BDD is scarce. Cognitive-behavioral therapy is the gold-standard psychosocial treatment for BDD in adults and has shown promise in adolescents. The current study examined the development and testing of a new CBT for adolescents with BDD. We tested feasibility, acceptability, and treatment outcome in a sample of 13 adolescents (mean age 15.23years, range: 13-17) with primary BDD. Treatment was delivered in 12-22 weekly individual sessions. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-months follow-up. At posttreatment, BDD and related symptoms (e.g., insight, mood) were significantly improved. Scores on the Yale-Brown Obsessive Compulsive Scale for BDD indicated a 50% (intent-to-treat) and 68% (completer) improvement in BDD symptoms. Seventy-five percent of adolescents who started treatment and 100% of completers were considered treatment responders. Treatment gains were maintained at follow-up. High patient satisfaction ratings and patient feedback indicated that treatment was acceptable. This represents the largest study of a psychosocial treatment for adolescent BDD.

Long-Term Outcome of Cognitive Behavior Therapy for Body Dysmorphic Disorder: A Naturalistic Case Series of 1 to 4 Years After a Controlled Trial

There is some evidence for the efficacy of cognitive behavior therapy (CBT) for body dysmorphic disorder (BDD) after 1 to 6months but none in the long term. The aim of this study was to follow up the participants in a randomized controlled trial of CBT versus anxiety management to determine whether or not the treatment gains were maintained over time. Thirty of the original 39 participants who had CBT were followed up over 1 to 4years and assessed using a number of clinician and self-report measures, which included the primary outcome measure of the Yale-Brown Obsessive Compulsive Scale modified for BDD. Outcome scores generally maintained over time from end of treatment to long-term follow-up. There was a slight deterioration from n=20 (51.3%) to n=18 (46.2%) who met improvement criteria at long-term follow-up. Eleven (28.2%) were in full remission and 22 (56.4%) were in partial remission. The gains made were generally maintained at long-term follow-up. However, there were a significant number of participants who maintained chronic symptoms after treatment and may need a longer-term or more complex intervention and active medication management.

Acceptance-Based Exposure Therapy for Body Dysmorphic Disorder: A Pilot Study

Body dysmorphic disorder (BDD) is an often severe, chronic, and disabling disorder, and although some controlled trials of cognitive behavior therapy (CBT) have shown efficacy, the body of evidence is still limited. The condition is generally considered difficult to treat, and further research to determine the effectiveness of psychological treatments for BDD is needed. The present study is the first to evaluate an acceptance-based therapy for BDD. In total, 21 patients received a 12-week group treatment consisting of weekly sessions of psychoeducation, acceptance and defusion practice, and exposure exercises to foster acceptance of internal discomfort and to strengthen the patients' committed purposeful actions. The primary outcome was BDD symptomatology (measured on the BDD-YBOCS) assessed by a psychiatrist before and after treatment and at 6months follow-up. The secondary outcomes were self-rated BDD symptoms, psychological flexibility, depressive symptoms, quality of life, and disability. Reductions in BDD symptomatology from pre- to posttreatment were significant and showed a large effect size, d=1.93 (95% CI 0.82-3.04). At posttreatment, 68% of the participants showed clinically significant improvement in the primary outcome variable. Treatment gains were maintained at 6months follow-up. The treatment also resulted in significant improvements in all secondary outcomes. The dropout rate was low; 90.5% of the participants completed treatment. This study suggests that acceptance-based exposure therapy may be an efficacious and acceptable treatment for BDD that warrants further investigation in larger controlled trials.

Therapist-guided, Internet-based cognitive-behavioural therapy for body dysmorphic disorder (BDD-NET): a feasibility study

OBJECTIVES

Cognitive-behavioural therapy (CBT) is an effective treatment for body dysmorphic disorder (BDD). However, most sufferers do not have access to this treatment. One way to increase access to CBT is to administer treatment remotely via the Internet. This study piloted a novel therapist-supported, Internet-based CBT program for BDD (BDD-NET).

DESIGN

Uncontrolled clinical trial.

PARTICIPANTS

Patients (N=23) were recruited through self-referral and assessed face to face at a clinic specialising in obsessive-compulsive and related disorders. Suitable patients were offered secure access to BDD-NET.

INTERVENTION

BDD-NET is a 12-week treatment program based on current psychological models of BDD that includes psychoeducation, functional analysis, cognitive restructuring, exposure and response prevention, and relapse prevention modules. A dedicated therapist provides active guidance and feedback throughout the entire process.

MAIN OUTCOME MEASURE

The clinician-administered Yale-Brown Obsessive Compulsive Scale for BDD (BDD-YBOCS). Symptom severity was assessed pretreatment, post-treatment and at the 3-month follow-up.

RESULTS

BDD-NET was deemed highly acceptable by patients and led to significant improvements on the BDD-YBOCS (p=<0.001) with a large within-group effect size (Cohen's d=2.01, 95% CI 1.05 to 2.97). At post-treatment, 82% of the patients were classified as responders (defined as≥30% improvement on the BDD-YBOCS). These gains were maintained at the 3-month follow-up. Secondary outcome measures of depression, global functioning and quality of life also showed significant improvements with moderate to large effect sizes. On average, therapists spent 10 min per patient per week providing support.

CONCLUSIONS

The results suggest that BDD-NET has the potential to greatly increase access to CBT, at least for low-risk individuals with moderately severe BDD symptoms and reasonably good insight. A randomised controlled trial of BDD-NET is warranted.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov registration ID NCT01850433.

Delusional versus nondelusional body dysmorphic disorder: recommendations for DSM-5

The core feature of body dysmorphic disorder (BDD) is distressing or impairing preoccupation with nonexistent or slight defects in one's physical appearance. BDD beliefs are characterized by varying degrees of insight, ranging from good (ie, recognition that one's BDD beliefs are not true) through "absent insight/delusional" beliefs (ie, complete conviction that one's BDD beliefs are true). The Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R) and The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) classified BDD's nondelusional form in the somatoform section of the manual and its delusional form in the psychosis section, as a type of delusional disorder, somatic type (although DSM-IV allowed double-coding of delusional BDD as both a psychotic disorder and BDD). However, little or no evidence on this issue was available when these editions were published. In this article, we review the classification of BDD's delusional and nondelusional variants in earlier editions of DSM and the limitations of their approaches. We then review empirical evidence on this topic, which has become available since DSM-IV was developed. Available evidence indicates that across a range of validators, BDD's delusional and nondelusional variants have many more similarities than differences, including response to pharmacotherapy. Based on these data, we propose that BDD's delusional and nondelusional forms be classified as the same disorder and that BDD's diagnostic criteria include an insight specifier that spans a range of insight, including absent insight/delusional BDD beliefs. We hope that this recommendation will improve care for patients with this common and often-severe disorder. This increased understanding of BDD may also have implications for other disorders that have an "absent insight/delusional" form.

Age at onset and clinical correlates in body dysmorphic disorder

OBJECTIVE

Age at onset is an important clinical feature of all disorders. However, no prior studies have focused on this important construct in body dysmorphic disorder (BDD). In addition, across a number of psychiatric disorders, early age at disorder onset is associated with greater illness severity and greater comorbidity with other disorders. However, clinical correlates of age at onset have not been previously studied in BDD.

METHODS

Age at onset and other variables of interest were assessed in two samples of adults with DSM-IV BDD; sample 1 consisted of 184 adult participants in a study of the course of BDD, and sample 2 consisted of 244 adults seeking consultation or treatment for BDD. Reliable and valid measures were used. Subjects with early-onset BDD (age 17 or younger) were compared to those with late-onset BDD.

RESULTS

BDD had a mean age at onset of 16.7 (SD=7.3) in sample 1 and 16.7 (SD=7.2) in sample 2. 66.3% of subjects in sample 1 and 67.2% in sample 2 had BDD onset before age 18. A higher proportion of females had early-onset BDD in sample 1 but not in sample 2. On one of three measures in sample 1, those with early-onset BDD currently had more severe BDD symptoms. Individuals with early-onset BDD were more likely to have attempted suicide in both samples and to have attempted suicide due to BDD in sample 2. Early age at BDD onset was associated with a history of physical violence due to BDD and psychiatric hospitalization in sample 2. Those with early-onset BDD were more likely to report a gradual onset of BDD than those with late-onset in both samples. Participants with early-onset BDD had a greater number of lifetime comorbid disorders on both Axis I and Axis II in sample 1 but not in sample 2. More specifically, those with early-onset BDD were more likely to have a lifetime eating disorder (anorexia nervosa or bulimia nervosa) in both samples, a lifetime substance use disorder (both alcohol and non-alcohol) and borderline personality disorder in sample 1, and a lifetime anxiety disorder and social phobia in sample 2.

CONCLUSIONS

BDD usually began during childhood or adolescence. Early onset was associated with gradual onset, a lifetime history of attempted suicide, and greater comorbidity in both samples. Other clinical features reflecting greater morbidity were also more common in the early-onset group, although these findings were not consistent across the two samples.

Symmetry Concerns as a Symptom of Body Dysmorphic Disorder

Symmetry obsessions are a common symptom of obsessive-compulsive disorder (OCD) and have several demographic and clinical correlates. Appearance-related symmetry concerns appear common in body dysmorphic disorder (BDD); however, no published studies have examined this topic. This study examined the clinical features, prevalence, and correlates of symmetry concerns involving physical appearance in two BDD samples (N=160 and N=115). More than 25% of participants in each sample reported symmetry concerns for a body part with which they were preoccupied (total of 18 body parts in sample 1 and 18 in sample 2). In sample 1, BDD participants with appearance-related symmetry concerns were older than those without appearance-related symmetry concerns. In sample 2, those with appearance-related symmetry concerns reported poorer mental health-related quality of life, were more likely to have experienced lifetime suicidal ideation, had better BDD-related insight, and were less likely to have a lifetime eating disorder. In both samples, participants with appearance-related symmetry concerns were more likely to have lifetime OCD but not OCD-related symmetry obsessions. Thus, symmetry is a common appearance concern in BDD that is associated with comorbid OCD but not with OCD symmetry concerns specifically, suggesting that symmetry concerns may have a different mechanism/pathophysiology in BDD versus OCD.

Cued panic attacks in body dysmorphic disorder

BACKGROUND

Body dysmorphic disorder (BDD) is a common and often severe disorder. Clinical observations suggest that panic attacks triggered by BDD symptoms may be common. However, to our knowledge, no study has examined such panic attacks in BDD. We investigated the prevalence, clinical features, and correlates of BDD- triggered panic attacks in individuals with this disorder.

METHODS

Panic attacks and other variables were assessed using reliable and valid measures in 76 individuals with lifetime DSM-IV BDD.

RESULTS

28.9% (95% CI, 18.5%-39.4%) of participants reported lifetime panic attacks triggered by BDD symptoms. The most common triggers of such attacks were feeling that others were looking at or scrutinizing the perceived appearance defects (61.9%), looking in the mirror at perceived defects (38.1%), and being in bright light where perceived defects would be more visible (23.8%). The most common panic attack symptoms were palpitations (86.4%), sweating (66.7%), shortness of breath (63.6%), trembling or shaking (63.6%), and fear of losing control or going crazy (63.6%). Compared to participants without such panic attacks, those with BDD-triggered panic attacks had more severe lifetime BDD, social anxiety, and depressive symptoms, as well as poorer functioning and quality of life on a number of measures. They were also less likely to be employed and more likely to have been psychiatrically hospitalized and to have had suicidal ideation due to BDD.

CONCLUSIONS

Panic attacks triggered by BDD-related situations appear com- mon in individuals with this disorder. BDD-triggered panic attacks were associated with greater symptom severity and morbidity.

A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder

BACKGROUND

This report prospectively examines the 4-year course, and predictors of course, of body dysmorphic disorder (BDD), a common and often severe disorder. No prior studies have prospectively examined the course of BDD in individuals ascertained for BDD. Method The Longitudinal Interval Follow-Up Evaluation (LIFE) assessed weekly BDD symptoms and treatment received over 4 years for 166 broadly ascertained adults and adolescents with current BDD at intake. Kaplan-Meier life tables were constructed for time to remission and relapse. Full remission was defined as minimal or no BDD symptoms, and partial remission as less than full DSM-IV criteria, for at least 8 consecutive weeks. Full relapse and partial relapse were defined as meeting full BDD criteria for at least 2 consecutive weeks after attaining full or partial remission respectively. Cox proportional hazards regression examined predictors of remission and relapse.

RESULTS

Over 4 years, the cumulative probability was 0.20 for full remission and 0.55 for full or partial remission from BDD. A lower likelihood of full or partial remission was predicted by more severe BDD symptoms at intake, longer lifetime duration of BDD, and being an adult. Among partially or fully remitted subjects, the cumulative probability was 0.42 for subsequent full relapse and 0.63 for subsequent full or partial relapse. More severe BDD at intake and earlier age at BDD onset predicted full or partial relapse. Eighty-eight percent of subjects received mental health treatment during the follow-up period.

CONCLUSIONS

In this observational study, BDD tended to be chronic. Several intake variables predicted greater chronicity of BDD.

A comparison study of body dysmorphic disorder versus social phobia

Body dysmorphic disorder (BDD) shares many characteristics with social phobia (SP), including high levels of social anxiety and avoidance, but to our knowledge no studies have directly compared these disorders' demographic and clinical features. Demographic and clinical features were compared in individuals with BDD (n=172), SP (n=644), and comorbid BDD/SP (n=125). SP participants had a significantly earlier age of onset and lower educational attainment than BDD participants. BDD participants were significantly less likely to ever be married than SP participants, had a greater likelihood of ever being psychiatrically hospitalized, and had significantly lower mean GAF scores than SP participants. The two groups had different comorbidity patterns, which included a greater likelihood for BDD participants to have comorbid obsessive-compulsive disorder (OCD) or an eating disorder, vs. a greater likelihood for SP participants to have a comorbid non-OCD anxiety disorder. The comorbid BDD/SP group had significantly greater morbidity across several domains than the SP only group, but not the BDD only group. In summary, although BDD and SP were similar across many demographic and clinical features, they had important differences. Future studies are needed to confirm these findings and address similarities and differences between these disorders across a broader range of variables.

Quality of life in body dysmorphic disorder

Body dysmorphic disorder (BDD) has a significant impact on the patients' quality of life (QOL). This is an initial literature review of QOL in patients with BDD, examining the extent of QOL impairments, the impact of psychiatric comorbidity on QOL, and the effect of treatment on QOL in BDD. Studies were identified through PubMed, MEDLINE, and PsycINFO searches from 1960-2011 using the keywords: "quality of life," "body dysmorphic disorder," "dysmorphophobia," and "body image." Studies included in this review were selected using specific criteria by two authors reaching consensus. Most BDD research studies have used symptom severity measures mainly to study BDD and its treatments. BBD with or without comorbidities is significantly associated with poor QOL and functioning. Studies show that treatment of BDD, either by psychopharmacological treatments such as selective serotonin reuptake inhibitors (SSRIs) or cognitive behavior therapy, might have positive effects on QOL, although these results need to be replicated in larger studies. In conclusion, QOL could add significant value to the assessment of BDD if used as one of the primary measures in research and clinical work in BDD, by providing more information and clearer understanding on the impact of the illness on satisfaction with activities of daily life and overall sense of wellbeing before and after treatment.

ERP, Medication, and Brief Hospitalization in the Treatment of an Adolescent With Severe BDD

This article describes the 2-year treatment of a 14-year-old girl suffering from severe body dysmorphic disorder (BDD) and comorbid major depressive disorder (MDD). Treatment consisted of twice-weekly sessions of exposure with response prevention (ERP), medication (fluoxetine), and a brief hospitalization for crisis stabilization. Continual (weekly) monitoring indicated significant reductions in daily obsessions and time spent in ritual. In addition, school attendance increased and scores on the Yale-Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder (BDD-YBOCS), Body Dysmorphic Disorder Examination (BDDE), and Children’s Depression Inventory (CDI) decreased. Gains were maintained at follow-up. At termination, the client met criteria for partial remission status as defined by Phillips, Pagano, Menard, and Stout. This case adds to the BDD treatment literature by evaluating the long-term effectiveness of a multicomponent intervention, as implemented in a naturalistic setting with an adolescent, and suggests that combination treatment may be required to reduce distress and to produce lasting changes in functioning.

Modular cognitive-behavioral therapy for body dysmorphic disorder

This study pilot tested a newly developed modular cognitive-behavioral therapy (CBT) treatment manual for body dysmorphic disorder (BDD). We tested feasibility, acceptability, and treatment outcome in a sample of 12 adults with primary BDD. Treatment was delivered in weekly individual sessions over 18 or 22 weeks. Standardized clinician ratings and self-report measures were used to assess BDD and related symptoms pre- and posttreatment and at 3- and 6-month follow-ups. At posttreatment, BDD and related symptoms (e.g., mood) were significantly improved. Treatment gains were maintained at follow-up. A relatively low drop-out rate, high patient satisfaction ratings, and patient feedback indicated that the treatment was highly acceptable to patients. To our knowledge, this represents the first test of a broadly applicable, individual psychosocial treatment for BDD.

Culturally Adapted Cognitive Behavioral Therapy for Body Dysmorphic Disorder: Case Examples

Individuals with Body Dysmorphic Disorder (BDD) have distressing or impairing preoccupations with imagined or slight defects in their appearance (e.g., nose too big). BDD is a severe psychiatric disorder often associated with high rates of suicidality as well as social and occupational impairment (Phillips, Coles et al., 2005). Researchers have only recently begun to investigate psychological treatments for BDD, with available data suggesting that cognitive behavioral therapy (CBT) appears efficacious for BDD (Williams, Hadjistavropoulos, & Sharpe, 2006). To our knowledge, however, there are no reports of whether CBT for BDD can be effectively generalized to ethnic minority and other special populations. The current report suggests specific modifications within the CBT for BDD framework that might improve the effectiveness and retention rates of CBT among ethnic minority patients with BDD. Specifically, the present study describes the cases of Ben, a 40-year-old, Jewish, married male, and John, a 30-year-old, African American, single male, both with a primary diagnosis of BDD. Various treatment techniques were used to make the course of CBT more culturally responsive. This case report illustrates the challenges and benefits of integrating cultural variables into a CBT framework for BDD, and it highlights the need for more work in this area.

Olfactory reference syndrome: demographic and clinical features of imagined body odor

OBJECTIVE

Olfactory reference syndrome (ORS) - preoccupation with a false belief that one emits a foul or offensive body odor - has been described around the world for more than a century. However, only a few small studies have systematically assessed ORS's clinical features.

METHOD

Twenty patients with ORS were systematically assessed using semistructured measures.

RESULTS

Subjects' mean age was 33.4±14.1; 60% were female. Preoccupation most often focused on the mouth (75%), armpits (60%) and genitals (35%). Bad breath (75%) and sweat (65%) were the most common odor descriptions. Currently, 85% of subjects had delusional ORS beliefs, 77% had referential thinking and 85% reported actually smelling the odor. Ninety-five percent of subjects reported performing one or more ORS-related repetitive behaviors (e.g., excessive showering). Forty percent had been housebound for at least 1 week because of ORS symptoms, 68% had a history of suicidal ideation, 32% had attempted suicide and 53% had been psychiatrically hospitalized. Forty-four percent of subjects had sought nonpsychiatric medical, surgical or dental treatment for the perceived odor, and one third had received such treatment, which was ineffective in all cases.

CONCLUSION

ORS appears to be characterized by high morbidity and seeking of nonpsychiatric treatment.

Cognitive-Behavioral Therapy for Youth with Body Dysmorphic Disorder: Current Status and Future Directions

Body dysmorphic disorder (BDD) usually begins during early adolescence and appears to be common in youth. BDD is characterized by substantial impairment in psychosocial functioning and high rates of suicidality. Cognitive-behavioral therapy (CBT) tailored to BDD is the best tested and most promising psychosocial treatment for adults. CBT has been used for youth with BDD, but has not been systematically developed for or tested in youth. This article focuses on CBT for BDD in adults and youth; possible adaptations and the need for treatment research in youth; and prevalence, clinical features, diagnosis, recommended pharmacotherapy, and treatments that are not recommended.

The clinical course of body dysmorphic disorder in the Harvard/Brown Anxiety Research Project (HARP)

This report prospectively examines the course of body dysmorphic disorder (BDD) for up to 8 years in a sample of 514 participants in the Harvard/Brown Anxiety Research Project, a naturalistic, longitudinal study of anxiety disorders. Diagnostic and Statistical Manual of Mental Disorders (4th ed.) BDD was assessed with a reliable semi-structured measure. For participants with BDD, severity of BDD symptoms was assessed with the Longitudinal Interval Follow-up Evaluation Psychiatric Status Rating scale. At the initial assessment, 17 participants (3.3%; 95% confidence interval = 1.8%-4.8%) had current BDD; 22 (4.3%; 95% confidence interval = 2.6%-6.1%) had lifetime BDD. Participants with BDD had significantly lower Global Assessment Scale scores than those without BDD, indicating poorer functioning. The probability of full recovery from BDD was 0.76, and probability of recurrence, once remitted, was 0.14 over the 8 years. In conclusion, among individuals ascertained for anxiety disorders, the probability of recovering from BDD was relatively high and probability of BDD recurrence was low.

Cognitive behavioral therapy for somatoform disorders

Patients presenting with somatoform disorders often incur excessive health care charges and fail to respond to standard treatment. The purpose of this article is to provide an overview of the diagnostic criteria and demographic and clinical characteristics of each somatoform disorder and to examine the research assessing the efficacy of cognitive behavioral therapy (CBT) for each disorder. The review shows that CBT has received some empirical support for somatization, hypochondriasis, and body dysmorphic disorder. However, there are few data on the impact of treatment on health care use, especially when the cost of CBT is factored into the equation. Too few methodologically sound studies have been published on the treatment of conversion disorder or of pain disorder to make any conclusions.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is a relatively common disorder that consists of a distressing or impairing preoccupation with imagined or slight defects in appearance. BDD is commonly considered to be an obsessive-compulsive spectrum disorder, based on similarities it has with obsessive-compulsive disorder. It is important to recognize and appropriately treat BDD, as this disorder is associated with marked impairment in psychosocial functioning, notably poor quality of life, and high suicidality rates. In this review, we provide an overview of research findings on BDD, including its epidemiology, clinical features, course of illness, comorbidity, psychosocial functioning, and suicidality. We also briefly review recent research on neural substrates and cognitive processing. Finally, we discuss treatment approaches that appear efficacious for BDD, with a focus on serotonin-reuptake inhibitors and cognitive-behavioral therapy.

A 2-year prospective follow-up study of the course of obsessive-compulsive disorder

BACKGROUND

Surprisingly little is known about the long-term course of obsessive-compulsive disorder (OCD). This prospective study presents 2-year course findings, as well as predictors of course, from the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the observational course of OCD in a large clinical sample.

METHOD

The sample included 214 treatment-seeking adults with DSM-IV OCD at intake who identified OCD as the most problematic disorder over their lifetime. Subjects were enrolled from 2001-2004. At annual interviews, data on weekly OCD symptom status were obtained using the Longitudinal Interval Follow-Up Evaluation. Probabilities of full remission and partial remission over the first 2 years of collected data and potential predictors of remission were examined.

RESULTS

The probability of full remission from OCD was 0.06, and the probability of partial remission was 0.24. Of the 48 subjects whose OCD symptoms partially or fully remitted, only 1 relapsed within the first 2 years. Earlier age at onset of OCD, greater severity of symptoms at intake, older age at intake, and being male were associated with a decreased likelihood of remission. Insight, diagnostic comorbidity, and treatment were not found to be associated with the likelihood of achieving full or partial remission.

CONCLUSIONS

Though one-quarter of the sample had periods of subclinical OCD symptoms during the prospective period, full remission was rare, consistent with the view of OCD as a chronic and persistent illness. Age at onset, OCD symptom severity, current age, and sex emerged as potent predictors of course.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

High-dose glycine treatment of refractory obsessive-compulsive disorder and body dysmorphic disorder in a 5-year period

This paper describes an individual who was diagnosed with obsessive-compulsive disorder (OCD) and body dysmorphic disorder (BDD) at age 17 when education was discontinued. By age 19, he was housebound without social contacts except for parents. Adequate trials of three selective serotonin reuptake inhibitors, two with atypical neuroleptics, were ineffective. Major exacerbations following ear infections involving Group A β-hemolytic streptococcus at ages 19 and 20 led to intravenous immune globulin therapy, which was also ineffective. At age 22, another severe exacerbation followed antibiotic treatment for H. pylori. This led to a hypothesis that postulates deficient signal transduction by the N-methyl-D-aspartate receptor (NMDAR). Treatment with glycine, an NMDAR coagonist, over 5 years led to robust reduction of OCD/BDD signs and symptoms except for partial relapses during treatment cessation. Education and social life were resumed and evidence suggests improved cognition. Our findings motivate further study of glycine treatment of OCD and BDD.

A prospective pilot study of levetiracetam for body dysmorphic disorder

INTRODUCTION

Body dysmorphic disorder (BDD) is an often severe disorder, but few treatment studies have been conducted.

OBJECTIVE

This pilot study explored the efficacy and safety of the antiepileptic medication levetiracetam for BDD.

METHODS

Seventeen subjects with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition BDD participated in a 12-week open-label levetiracetam trial. Subjects were assessed at regular intervals with standard measures.

RESULTS

In intent-to-treat analyses, scores on the Yale-Brown Obsessive Compulsive Scale Modified for BDD (BDD-YBOCS), the primary outcome measure, decreased from 32.5+/-4.7 at baseline to 21.5+/-11.0 at endpoint (P<.001). Approximately 60% (n=9) of subjects were responders (>30% decrease on the BDD-YBOCS). The mean time to response was 4.6+/-2.8 (range: 2-10) weeks. Scores also significantly improved on the Brown Assessment of Beliefs Scale, the Hamilton Rating Scale for Depression, the Global Assessment of Functioning Scale, and the Social and Occupational Functioning Assessment Scale. Scores did not significantly improve on the Quality of Life Enjoyment and Satisfaction Questionnaire, the Beck Anxiety Inventory, or the Social Phobia Inventory. The mean endpoint dose of levetiracetam was 2,044.1+/-1,065.2 (range: 250-3,000) mg/day, and it was relatively well-tolerated.

CONCLUSION

Randomized, double-blind placebo-controlled studies of levetiracetam for BDD are needed to confirm these preliminary findings.

Body dysmorphic disorder: treating an underrecognized disorder

“Mr. H,” a 33-year-old single white male, presented with preoccupations focused on his “thinning” hair, facial “acne,” and “short” fingers. He began to worry excessively about his appearance at age 15, focusing at that time on his “pale” skin and “uneven” cheekbones. Mr. H described his appearance preoccupations as “severely upsetting,” but he was too embarrassed to reveal them to family or friends. Even though he looked normal to others, Mr. H was “100% convinced” that these body areas appeared “abnormal and deformed,” although in the past he had sometimes thought that “maybe I don't look so bad.” He believed that other people took special notice of him and “laugh at me behind my back because I look so ugly.” Mr. H spent 5 to 6 hours a day thinking about his perceived appearance flaws. He also performed compulsive behaviors for 4 to 5 hours a day, which included excessive mirror checking, comparing his appearance with that of other people, wearing and frequently adjusting a baseball cap to cover his hair, picking his skin to remove tiny blemishes, and searching the Internet for acne and hair loss treatments. Mr. H's appearance preoccupations and compulsive behaviors made it difficult to concentrate on his job as a store clerk and often made him late for work. In the past few weeks, he had missed work several times because he thought his skin looked particularly bad on those days. Mr. H avoided many social events with family and friends as well as sexual intimacy with his girlfriend because of shame over how he looked. In addition, he reported depressed mood, anhedonia, feelings of worthlessness, and passive suicidal ideation, and he had attempted suicide 5 years ago. He attributed his depressive symptoms and suicidal thinking to his appearance concerns, stating, “If I didn't look like such a freak, I wouldn't feel so hopeless and depressed.” Mr. H had received treatment from a dermatologist for his acne concerns, which did not diminish his preoccupations. He had never received psychiatric treatment and was ambivalent about trying it because, as he stated, “my appearance problems are real.”

Psychopathologic aspects of body dysmorphic disorder: a literature review

Body dysmorphic disorder (BDD) is a somatoform disorder characterized by the patient's excessive concern with an imagined or minor defect in physical appearance. Patients with BDD often have been observed in aesthetic surgery settings seeking surgical enhancement at a reported prevalence of 6% to 15%. Published studies in the general population tend to aggregate a prevalence of 0.7% to 2.3%. This review aimed to search the literature for data on the prevalence, psychopathologic aspects, and comorbidity of BDD, and to provide an update on current BDD research. Relevant literature was identified by searching the Medline, PubMed, PsycINFO, and EMBASE databases. The following search words were used alone or in combination when appropriate: "body dysmorphic disorder," "somatoform disorder," "obsessive compulsive spectrum disorder," "personality disorders," "presurgical counseling," "aesthetic surgery," "cosmetic surgery," and "plastic surgery." Further articles were sourced from the reference lists of the articles ascertained through the search. Recent findings include the relationship between BDD and the obsessive-compulsive spectrum, treatment of BDD based on pharmacologic and psychological approaches, and the hypothesis that the often distinguished delusional and nondelusional variants of BDD very likely are the expression of a single disorder with varying degrees of severity. Retrospective outcome studies suggest that patients affected by BDD typically do not benefit from surgical treatment. In contrast, serotonin reuptake inhibitors and cognitive-behavior therapy appear to be good practice in addressing the disorder. Further research is needed to identify effective interventions for patients who do not respond to these treatment methods.

The prevalence of body dysmorphic disorder in the United States adult population

OBJECTIVE

In clinical samples, body dysmorphic disorder (BDD) is associated with substantial suffering and reduced quality of life. Limited surveys report widely varying prevalence estimates. To better establish the prevalence of BDD, we conducted a United States nationwide prevalence survey.

METHOD

We conducted a random sample national household telephone survey in the spring and summer of 2004 and interviewed 2,513 adults, of whom 2,048 qualified for the BDD-module administration. The computer-assisted, structured interviews, conducted by trained lay interviewers, addressed Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BDD, along with information regarding several impulse-control disorders and the respondents' financial and demographic data.

RESULTS

The rate of response was 56.3%, which compared favorably with rates in federal national health surveys. The cooperation rate was 97.6%. Respondents included a higher percentage of women and people >55 years of age than in the US adult population, and a lower percentage of Hispanics. The estimated point prevalence of DSM-IV BDD among respondents was 2.4% (49/2,048) (by gender: 2.5% for women, 2.2% for men), exceeding the prevalence of schizophrenia and bipolar disorder type I and about that of generalized anxiety disorder. BDD prevalence decreased after 44 years of age, and a larger proportion of BDD respondents were never married. Of those meeting DSM-IV criteria for BDD, 90% (45/49) met the DSM-IV distress criterion, and 51% (25/49) met the interference-with-functioning criterion.

CONCLUSION

A study using clinically valid interviews is needed to evaluate these results. Such studies could inform treatment by documenting rates of seeking treatment from various sources, suicide attempt rates, and the prevalence of comorbid conditions.

Impact of helping behaviors on the course of substance-use disorders in individuals with body dysmorphic disorder

OBJECTIVE

Alcoholics Anonymous and 12-step facilitated treatments for substance-use disorders (SUDs) encourage individuals with SUD to consider the needs of others and engage in helping behaviors as a method to become sober. SUDs are one of the most common comorbid disorders among individuals with body dysmorphic disorder (BDD). The purpose of this study is to examine prospectively the relationship between helping behaviors and the likelihood of SUD and BDD remission.

METHOD

Data on 163 individuals during the course of 3 years were derived from the Prospective Study of Body Dysmorphic Disorder, a longitudinal investigation of patterns and predictors of the course of BDD. Kaplan-Meier survival estimates were used to calculate probabilities of time to BDD and SUD remission. Cox regression analyses were conducted to calculate the relative likelihood of levels of helping behaviors as time-varying predictors of remission from both SUD and BDD.

RESULTS

The course of SUD and BDD was chronic for most subjects; the estimated probability of remission from an SUD across 3 years was .29 and .17 for a full BDD remission. Results indicated that increases in helping behaviors were significantly predictive of SUD remission (hazard ratio [HR] = 2.59, p = .0134). Helping behaviors were also predictive of BDD remission among those with or without SUD but at a trend level of significance (HR = 1.51, p = .0676).

CONCLUSIONS

These findings extend previous work reporting significant relationships between helping behaviors and positive long-term SUD outcomes. Implications of the mechanisms involved in the link between helping behaviors and remission from SUD and BDD are discussed.

The relationship of body dysmorphic disorder and eating disorders to obsessive-compulsive disorder

Body dysmorphic disorder (BDD) and eating disorders are body image disorders that have long been hypothesized to be related to obsessive-compulsive disorder (OCD). Available data suggest that BDD and eating disorders are often comorbid with OCD. Data from a variety of domains suggest that both BDD and eating disorders have many similarities with OCD and seem related to OCD. However, these disorders also differ from OCD in some ways. Additional research is needed on the relationship of BDD and eating disorders to OCD, including studies that directly compare them to OCD in a variety of domains, including phenomenology, family history, neurobiology, and etiology.

Body dysmorphic disorder and social phobia: cross-sectional and prospective data

Much attention has been paid to the relationship between body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD). However, to our knowledge, no published study has focused directly on the relationship between BDD and social phobia (SP). This is striking given similar clinical features of the two disorders, data showing elevated comorbidity between them, and Eastern conceptualizations of BDD as a form of SP. In this study, 39.3% of 178 individuals with current BDD had comorbid lifetime SP, and 34.3% had current SP. SP onset was typically before BDD. Individuals with BDD, with and without lifetime SP, were similar on many general characteristics (e.g., age of BDD onset, gender distribution, BDD severity, overall functional disability). However, subjects with BDD+SP were significantly less likely to be employed, were more likely to report lifetime suicidal ideation, and had poorer global social adjustment on one of two measures. Both BDD and SP were associated with elevated social anxiety; subjects with BDD+SP experienced additional social anxiety that appeared independent of BDD symptoms. Examining 1-year prospective data available for 161 subjects, BDD+SP subjects were somewhat less likely to experience remission (partial or full) of their BDD symptoms over 1-year follow-up, although this difference was not statistically significant (hazard ratio = .64, P = .18). In summary, these findings, including elevated rates of SP in patients with BDD, highlight a need for additional research on the relationship between BDD and SP.